Friday, March 07, 2014

The Needle and the Gun

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The
recent announcement by the Egyptian government that the Armed Forces have
discovered a device to detect and possibly cure hepatitis “C” and AIDS has been
met with disbelief, ridicule and occasional contempt.It was not met with a great deal of anger, but perhaps this
was because Egyptians were all too aware of the context within which the device
has been offered. Or perhaps after
three years of revolutionary upheaval many Egyptians are too exhausted. The
foreign media has echoed some of the ridicule but with rare exceptions has been
either willfully or blindly ignorant of the public health background of the
last two decades. Whether these events were an indication of malice, hypocrisy,
incompetence or simple lack of attention by the relevant authorities remains
uncertain.

Announced
at a mid-February 2014 press conference by Ibrahim Abdel Atti, a general by
courtesy, the device—named C-Fast—resembles a radio antenna connected to a
trigger mechanism. It is thus
supposed to be instantaneous (whence its name) and non-invasive. Abdel Atti
claims that he spent two decades developing the device, most recently with
support from the Armed Forces.Similar
technology, he claimed, was at use in “complete cure” which ostensibly did what
its name implied.Several Egyptian
scientists, including the president’s science adviser, have publicly announced
that the device itself is most likely a fake and that neither the device nor
the theory on which it was supposedly developed has any validity.

If
the underlying health issues were less serious the events of the past week
might have the quality of an arcane comedy or a peculiar vaudeville act. But there
is every reason for Egyptians to be worried about hepatitis C.It is a severe liver disease whose full
effects may take decades to manifest.These include cancer of the liver and cirrhosis either of which is fatal
if untreated.The most
common medications are uncertain and require a course of treatment lasting
months.Even after government
assistance, they may cost hundreds or thousands of dollars which puts them
beyond the reach of many of Egypt’s poor who may subsist on $2 a day.

As
a story in the New York Times on February 26, 2014 coyly noted Egypt has “the
highest prevalence of hepatitis C.”The superlative here refers to the entire globe: the rate of infection
among Egyptians is the world’s highest.According to a report issued by the US Centers for Disease Control but
largely authored by Egyptian specialists about 10 % of the Egyptian population,
or 6 million people in 2008, had chronic hepatitis c virus (HCV)
infection.Egypt, with less
than a quarter the population of the United States has twice as many people
infected with the virus.Another
telling comparison is that Egypt with less than 1% of the world’s population
has roughly 4% of the world’s cases of hepatitis C.

In
general hepatitis C rates are higher in the countryside than the cities, among
men than women, and among those who are older.The same report indicates that between 2008 and 2011 the
Egyptian government treated about 190,000 Egyptians with one or two medications
that cure between 60 and 80% of cases.However, about 40,000 Egyptians die every year due to liver cancer or
cirrhosis (not all of which is attributable to HCV) and it is the second
highest cause of death in the country after heart attacks.

There is every reason for
Egyptians, especially the poor and the illiterate, to be concerned about
hepatitis C and to hope that someone can develop a quick and inexpensive
treatment. That many Egyptians
welcomed the claims about C-Fast is not surprising. There is no particular
reason that ordinary Egyptians should have very clear ideas about the best
science for the detection and cure of AIDS or hepatitis C.Whatever the vices of General Abdel
Atti’s device, it has the virtue of being harmless in itself.This is more than can be said of a drug
such as laetrile that was popular in the United States at least through the
1970s and is still occasionally touted as a cure for cancer.Laetrile, made from apricot pits, has
no impact on cancer but it does contain sufficient cyanide that patients taking
it have a real risk of being poisoned.

The
problem with a harmless treatment is that it induces a false sense of security
among patients who will nevertheless succumb to a deadly disease.It is not clear whether the peak
incidence of the disease occurred in the past several years but it will be a
severe public health problem for decades to come.

That
the epidemic itself was in large part the effect of an earlier Ministry of
Health program designed to eliminate endemic schistosomiasis (also known as
bilharzia) was well known and recently reported in The Economist.Schistosomiasis also causes severe
liver disease.That campaign
itself was necessitated by earlier decisions by many Egyptian governments
(including those at the turn of the 20th century when the country
was effectively under British control) to extend perennial irrigation.Egyptians suffered from schistosomiasis
thousands of years ago but perennial irrigation allowed a parasite that moves
from snails to humans and back again to routinely complete its life cycle and
infect large numbers of people.

From 1960 until around 1980 the
government injections of tartar emetic were used to control schistosomiasis.The decision by the government to
employ re-usable glass syringes that were often not effectively sterilized
between uses spread the HCV epidemic even as it began to reduce the incidence
of schistosomiasis.By the
mid-1980s an oral drug had begun to replace the earlier treatment.Unfortunately by then HCV was endemic
and an unrelated hepatitis B virus had also begun to spread.

There are other sources for the
spread of HCV.The growing
incidence of adult diabetes has also led to a growing incidence of kidney
failure (more formally, end stage renal disease).As a consequence more Egyptians are undergoing dialysis
which, when the machines are not adequately sterilized, has become another
vector for the spread of HCV.

Egypt has more than 1,000 dialysis units
that provide care for patients with kidney disease.Dialysis costs about $3200 a year for three treatments a
week (in the US the cost is about 50 times as great and would also be beyond
the reach of most who suffer from the disease if Medicare did not pick up the
bill). This is well beyond the
income of most Egyptians with ESRD.Needless to say 1,000 units is far from sufficient for a country with
millions who have ESRD.Recent
estimates indicate that about 10% of Egyptians suffer from diabetes (about half
of which is undiagnosed) and perhaps twice that many suffer from hypertension
which is the other major precursor to ESRD.

Dialysis clinics are spread
throughout the country but are most easily available in the large cities.Thus there is relatively large dialysis
center not far from Tahrir Square tucked into a small side street opposite an
art gallery and not far from automobile repair shops.In Giza, on the boundary between the upscale neighborhood of
Muhandiseen and impoverished area of Imbaba there are several clinics
specializing in kidney and liver disease.At the height of the demonstrations in Tahrir Square, empty as the
streets of Cairo and Giza may have been, the clinics were filled with patients,
some from Upper Egypt and some from upper class Cairene families waiting to see
their physicians and watching the news reports on television.Neither kidney nor liver patients could
let revolution prevent their search for treatment.My only reason for being aware of this is that I spent most
of a day there on several occasions waiting for my own appointment.

Treatment
of HCV has been expensive and until recently quite uncertain.In December 2013 the English-language
Ahram reported news of a trial in the US. These results were clearly well known
to officials of the Health Ministry.The US Food and Drug Administration has recently approved an orally delivered medication that is
extremely effective when used to treat the particular variation of HCV common
in Egypt.Dr. Wahid Doss, head of
the Egyptian National Liver Institute, was quoted in news reports (including
the Ahram report) about the results of a study in the United States that showed
Sofusbuvir in conjunction with Peginterferon and Ribavirin achieved a 97%
permanent clearance rate of the virus after 12 weeks of treatment.

All
of this information and more was available to the Egyptian government and
Egyptian medical organizations and it was in the public record when the first
reports of C-Fast were made.In
the space of a week and a half the emptiness of the claims of Abdel Atti and
the C-Fast device had been revealed.On the positive side it is apparent that the repressive as the new
government may be and despite the danger of scientific quackery Egypt’s
scientific community remains active.It is easy to dismiss the value of expertise but for many Egyptians
today in many areas of society there is a far greater problem in not having
access to expert advice and care than in having too much of it.

The size of the public health
tragedy that confronts the country and the very limited resources for dealing
with it are truly daunting.Much
as been written of the macroeconomic challenges Egypt faces, the cost of fuel
and food subsidies, the continuing problems with electricity supply and
butane.And of course there is
repressive response of the state to public political opposition.

The 2011 electoral program of the
Muslim Brotherhood’s Freedom and Justice party correctly noted the extent of
the hepatitis and diabetes epidemic facing the country but proposed no
immediate proposals to address it and no significant increase in funding
already existing institutions or policy initiatives.The current government is clearly aware of the extent of the
crisis and of how it affects the lives of ordinary Egyptians.Despite information available from the
government’s own scientific advisers and the Egyptian professional medical
community, the government promoted a quack response.Had the C-Fast device not been critiqued, ridiculed and (one
can only hope) withdrawn, its use would have been worse than doing nothing.It is sobering to realize that every month
almost as many Egyptians unnecessarily die due to the consequences of
government incapacity and inaction as were killed in the public squares in the
summer of 2013.These deaths are
unintended and clearly cannot be considered the policy of the state. No violation of rights is involved.They are nevertheless a significant
human tragedy for which negligence may be a reason but not really an excuse.